Crisis intervention for people with severe mental illnesses

Background A particularly difficult challenge for community treatment of people with serious mental illnesses is the delivery of an acceptable level of care during the acute phases of severe mental illness. Crisis-intervention models of care were developed as a possible solution. Objectives To review the effects of crisis-intervention models for anyone with serious mental illness experiencing an acute episode compared to the standard care they would normally receive. If possible, to compare the effects of mobile crisis teams visiting patients' homes with crisis units based in home-like residential houses. Search methods We searched the Cochrane Schizophrenia Group’s Study-Based Register of Trials. There is no language, time, document type, or publication status limitations for inclusion of records in the register. This search was undertaken in 1998 and then updated 2003, 2006, 2010 and September 29, 2014. Selection criteria We included all randomised controlled trials of crisis-intervention models versus standard care for people with severe mental illnesses that met our inclusion criteria. Data collection and analysis We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assessed risk of bias for included studies and used GRADE to create a 'Summary of findings' table. Main results The update search September 2014 found no further new studies for inclusion, the number of studies included in this review remains eight with a total of 1144 participants. Our main outcomes of interest are hospital use, global state, mental state, quality of life, participant satisfaction and family burden. With the exception of mental state, it was not possible to pool data for these outcomes. Crisis intervention may reduce repeat admissions to hospital (excluding index admissions) at six months (1 RCT, n = 369, RR 0.75 CI 0.50 to 1.13, high quality evidence), but does appear to reduce family burden (at six months: 1 RCT, n = 120, RR 0.34 CI 0.20 to 0.59, low quality evidence), improve mental state (Brief Psychiatric Rating Scale (BPRS) three months: 2 RCTs, n = 248, MD -4.03 CI -8.18 to 0.12, low quality evidence), and improve global state (Global Assessment Scale (GAS) 20 months; 1 RCT, n = 142, MD 5.70, -0.26 to 11.66, moderate quality evidence). Participants in the crisis-intervention group were more satisfied with their care 20 months after crisis (Client Satisfaction Questionnaire (CSQ-8): 1 RCT, n = 137, MD 5.40 CI 3.91 to 6.89, moderate quality evidence). However, quality of life scores at six months were similar between treatment groups (Manchester Short Assessment of quality of life (MANSA); 1 RCT, n = 226, MD -1.50 CI -5.15 to 2.15, low quality evidence). Favourable results for crisis intervention were also found for leaving the study early and family satisfaction. No differences in death rates were found. Some studies suggested crisis intervention to be more cost-effective than hospital care but all numerical data were either skewed or unusable. We identified no data on staff satisfaction, carer input, complications with medication or number of relapses. Authors' conclusions Care based on crisis-intervention principles, with or without an ongoing homecare package, appears to be a viable and acceptable way of treating people with serious mental illnesses. However only eight small studies with unclear blinding, reporting and attrition bias could be included and evidence for the main outcomes of interest is low to moderate quality. If this approach is to be widely implemented it would seem that more evaluative studies are still neede

Heterogeneity: the issue of apples, oranges and fruit pie.

Heterogeneity refers to any kind of variation among studies contributing to the same outcome in a systematic review. There are three broad types of heterogeneity: clinical heterogeneity, methodological heterogeneity and statistical heterogeneity. In this paper, we describe these three types of heterogeneity and the main statistical approaches to measure heterogeneity

Using the needs of WHO to prioritise Cochrane reviews: The case of antipsychotic drugs

ABSTRACT: BACKGROUND: This study aimed to investigate existing trialling activity relating to three antipsychotic drugs from the WHO List of Essential Medicines (chlorpromazine, fluphenazine decanoate, haloperidol), link existing trials to existing Cochrane reviews, identify gaps in reviewing activity on accessible treatments for people with schizophrenia. METHOD: S We used the Cochrane Schizophrenia Group's register searching for all studies comparing the three antipsychotic drugs with each other and with all other pharmacological interventions listed on the Essential Medicines List (with the addition of 'placebo or no drug'). For each we also considered studies that focussed on administration, dose, withdrawal and use of that drug in specific circumstances administration.Data were then extracted on a number of studies, number of participants within those studies, and as to whether a maintained review already exists. Finally, every effort was made to consider as to whether there were possibilities for missing comparisons that no one had ever investigated. RESULTS: There has been considerable research activity involving the three 'essential' antipsychotics and also comparing those three drugs to others on the 'essential' list. We found 490 studies with 77957 participants for haloperidol, 316 studies with 29179 participants for chlorpromazine and 33 studies with 4503 participants for fluphenazine decanoate. Reviewing activity has also been considerable in this area but there are notable omissions which would necessitate new reviews to comprehensively cover the area. CONCLUSIONS: We have used the 'sample frame' of the WHO Essential drug list as a starting point. WHO prioritises for us those drugs that have universal accessibility but they may not be the compounds that are first choice if others are available. It is encouraging to see how many maintained reviews already exist to service those undertaking WHO guidelines. The needs of those guiding care can be taken as a means of prioritising research. For largest global impact WHO Essential Medicine list provides clear direction. By using this technique workload can be anticipated, prioritising can take place for new reviews and updates

Using built-in functions of Adobe Acrobat Pro DC to help the selection process in systematic review of randomized trials

This letter describes a simple way of using Adobe Acrobat Pro DC to help select and auto-extract data from Portable Document Format (PDFs) of randomised trials in order to assist swift early selection of trials for a systematic revie

Rivers of Evidence

There has been too much of a one-way flow drift down a river of evidence. Researchers from rich countries have produced the primary evidence which they proceed to summarise within reviews. These summaries have directed care worldwide. However, things are changing and the river of evidence can flow in the other direction. The care of women with eclampsia has been changed or refined throughout the world because of a large low and middle income country trial. The global care of people with heart disease has been greatly modified by studies originating in China. The care of people who are acutely aggressive because of psychosis has to be reconsidered in the light of the evidence coming from Brazil and India. Healthcare is an issue everywhere and evaluation of care is not the premise of any one culture—the evidence—river must run both ways

Clothiapine for acute psychotic illness: a meta-analysis

Objectives: To estimate the effects of clothiapine, a dibenzothiazepine neuroleptic, for the management of acute psychosis.Methods: Six databases were searched, reference lists were inspected and relevant industry and authors contacted. Randomised clinical trials involving clothiapine for acute psychosis were identified and relevant data extracted.Results: Five relevant trials were found comparing clothiapine with antipsychotics or lorazepam. We found no evidence to support or refute the use of clothiapine in the psychiatric emergency (no significant improvement compared with other antipsychotics RR 0.82, 95% CI 0.2 to 3.1, heterogeneous p=0.09, N=83; no difference in mental state change when clothiapine was compared to lorazepam WMD -3.36 95%CI -8.09 to 1.37, N=60). Clothiapine may result in less need for antiparkinsonian treatment than zuclopenthixol acetate (RR 0.43, 95%CI 0.02 to 0.98, N=38).Conclusions: Wide confidence intervals prevent any firm conclusions, but clothiapine could be effective and cheap for rapid tranquillisation.S Afr Psychiatry Rev 2003;6:12-1

A simple formula for enumerating comparisons in trials and network meta-analysis [version 1; referees: 2 approved]

We present use of a simple formula to calculate the number of pairwise comparisons of interventions within a single trial or network meta-analyses. We used the data from our previous network meta-analysis to build a study-based register and enumerated the direct pairwise comparisons from the trials therein. We then compared this with the number of comparisons predicted by use of the formula and finally with the reported number of comparisons (indirect or direct) within the network meta-analysis. A total of 133 trials included in the network generated 163 comparisons (16 unique direct comparisons for 8 interventions). The formula predicted an expected 28 indirect or direct comparisons and this is the number that were indeed reported. The formula produces an accurate enumeration of the potential comparisons within a single trial or network meta-analysis. Its use could help transparency of reporting should a shortfall occur between comparisons actually used and the potential total

A simple formula for enumerating comparisons in trials and network meta-analysis [version 2; peer review: 2 approved]

We present use of a simple formula to calculate the number of pairwise comparisons of interventions within a single trial or network meta-analyses. We used the data from our previous network meta-analysis to build a study-based register and enumerated the direct pairwise comparisons from the trials therein. We then compared this with the number of comparisons predicted by use of the formula and finally with the reported number of comparisons (indirect or direct) within the network meta-analysis. A total of 133 trials of 8 interventions were selected which included 163 comparisons. The network of these showed 16 unique direct comparisons. The formula predicted an expected 28 indirect or direct comparisons and this is the number that were indeed reported. The formula produces an accurate enumeration of the potential comparisons within a single trial or network meta-analysis. Its use could help transparency of reporting should a shortfall occur between comparisons actually used and the potential total